Hidden Threats for Hospitals

The EMS Chart May Be Hindering Joint Commission Compliance

In 2016, the Joint Commission published a report that illustrated the nation’s level of noncompliance with Joint Commission standards. One such standard — Record of Care (RC) 01.01.01, the foundational standard for patients’ medical records — is a perennial top 10 on the list of most frequently cited standards. In the acute care hospital space, failure to comply with RC 01.01.01 was 49% in 2014, and in 2015 it remained an abysmal 47%.

Failure to incorporate an Emergency Medical Services (EMS) prehospital care report into the patient’s clinical record signals an auditor that a historical record of the patient’s episode of care is incomplete.

Did you know that the complete clinical record, as defined by the Joint Commission, comprises episodic care that extends beyond your hospital? More to the point, the Joint Commission places total responsibility on your hospital for collating all emergency treatment and clinical care provided for your patient’s episode of care. In practical application, failure to incorporate an Emergency Medical Services (EMS) prehospital care report into the patient’s clinical record signals an auditor that a historical record of the patient’s episode of care is incomplete.

But wait, it gets worse: When the record is incomplete, the auditor has no way of concluding that communication occurred between practitioners and staff to facilitate adequate diagnoses, support continuity of care, and aid in clinical decision-making.

Do you know your hospital’s compliance rate for merging EMS prehospital care reports into your patients’ clinical care records? Does your compliance performance rise significantly with your primary EMS provider, but wain dramatically with secondary or tertiary EMS providers? If you don’t know the answers, you’re in good company: Many acute care hospitals are surprised to find that their compliance rate with just this fractal of the question yields greater than 60% noncompliance.

So what are you doing to automate the process of incorporating the EMS record into the clinical salient patient record?